Controlled Substances Not Secured Under Double Lock in Medication Room
Penalty
Summary
Surveyors observed that controlled substances, specifically four bottles of liquid lorazepam and two bottles of liquid morphine, were stored in an unlocked box inside an unlocked refrigerator in the main medication room. The Director of Nursing (DON) confirmed that the box containing these controlled substances should always be locked, and Nurse #2, who had the key, acknowledged that she had forgotten to lock the box after counting the medications with the third shift nurse earlier that morning. The Administrator stated that her expectation was for all controlled substances to be locked at all times, whether stored in the medication cart or refrigerator. This failure to secure controlled substances under a double lock in the medication room was directly observed and confirmed through staff interviews, constituting a deficiency in the facility's medication storage practices.